Confidential Criminal History Check

Confidential Criminal History Check
The Navarro Independent School District is required by Texas Education Code Chapter 22, Subchapter C, to review the criminal
history of applicants, employees, independent contractors, student teachers, and volunteers. The information requested below is
necessary to obtain criminal history record information and for fingerprinting purposes.
Please Print all Information
Name: ______________________________________________________________________________
Last (Legal name as shown on SS card) First
Middle
Social Security #: _________________________
Date of Birth: _________________________
Driver’s License or State ID: ________________ Phone #: _____________________________
State / Number
Mailing Address: ______________________________________________________________________
Street
City
State
Zip
Sex:
Male
Female
Ethnicity:
Black
Hispanic
White/Other
I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility
for employment but will be used solely for the purpose of obtaining criminal history record information.
Applicant for:
Professional
Certified Teacher
Administrative Support/Paraprofessional
Substitute Teacher
Substitute Paraprofessional (Secretary/Aide)
Student Teacher/Observer
Operations:
Maintenance/Custodial
Transportation
Food Services
Substitute
Maintenance/Custodial/Food Services
School District Volunteer:
Campus/Classroom/Chaperone
Other: ______________________
Please list campus or area: ___________________
(please list)
Please read and sign the reverse side of this form. All
incomplete forms will be returned and delay the process.
Signature: __________________________________________ Date:
==================================
CCH Report printed:
Yes
FOR DISTRICT USE ONLY
================================
No Initial: _______ Purpose: __________________ Approved/Hired
Date: ________________________________
Destroy Date: __________________
Yes
No __________
Initial: _________________
HR Forms
Rev. 1/2012
NAVARRO INDEPENDENT SCHOOL DISTRICT
P. O. Drawer 10 Geronimo, TX 78115  6450 N. State Hwy. 123 Seguin, TX 78155
830-372-1930 phone  830-372-1853 fax
www.nisd.us
An Equal Opportunity Employer
NISD considers applicants for all positions without regard to race, color, national origin, age, religion,
sex, marital status, veteran or military status, disability, or any other legally protected status.
STUDENT TEACHER APPLICATION
PERSONAL DATA
Date of Application
Name
Last
First
Middle Initial
Current address
Street/Box
City
State
ZIP Code
Other mailing address _________________________
Primary Phone
Email address
Other name(s) that may appear on records
(Used for certification, reference, and criminal history record checks)
University currently attending: __________________________________________________________
Please attach an unofficial copy of your college transcript showing completed hours:
Application will be considered incomplete until transcript is provided.
Have you been employed by Navarro ISD in the past?
 Yes
 No
If you answered yes, provide dates of employment
EDUCATION / TRAINING
Name and Location of Schools Attended
Course of Study,
Major and Minor
Diploma, degree,
certificate, or license
ANTICIPATED CERTIFICATION
-1-
HR Forms 10/11
EMPLOYMENT EXPERIENCE - List experience beginning with most recent position
Name and location
Position/Title
Dates
Employed
Reason for leaving
REFERENCES
Please list references the district can contact regarding your work history. Include all managers and
supervisors who evaluated or supervised your performance at your last two employers.
Full Name of Reference
School District /
Firm Name
Mailing Address
Position/Title
Area Code,
Phone No.
GENERAL INFORMATION
Have you ever been convicted of, pleaded guilty or no contest (nolo contendre) to, or received
probation, suspension, or deferred adjudication for a felony, or any offense involving moral turpitude
(including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)?
 Yes
 No
If yes, please state where, when, and the nature of the offense
______________________________________________________________________________
______________________________________________________________________________
A Felony conviction is not an automatic disqualification of employment. The NISD will consider the
nature, date, and relationship between the offense and the position for which you are applying.
VERIFICATION
This application becomes the property of the district. The district reserves the right to accept or reject it.
I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and
understand that any deliberate falsifications, misrepresentations, or omissions of facts may be grounds for rejection of
my application or dismissal from subsequent employment.
I authorize the references listed on the previous page to give you any and all information concerning my previous
employment and any pertinent information they may have, personal or otherwise, and release all such parties from
liability for any damage that may result from furnishing the same to you.
I understand that the district is authorized by Texas Education Code §22.083 to obtain criminal history record
information and fingerprinting results on applicants the district intends to employ. By completing the CHR form, I
authorize the district to obtain and review CHR fingerprinting results.
Signature
-2-
Date
HR Forms 10/11
Confidential Criminal History Check
The Navarro Independent School District is required by Texas Education Code Chapter 22, Subchapter C, to review the criminal history of
applicants, employees, independent contractors, student teachers, and volunteers. The information requested below is necessary to obtain
criminal history record information and for fingerprinting purposes.
Please Print all Information
Name: ______________________________________________________________________________
Last (Legal name as shown on SS card) First
Middle
Social Security #: _________________________
Date of Birth: ________________________
Driver’s License: _________________________ Phone #: _____________________________
State
Number
Mailing Address: ______________________________________________________________________
Street
City
State
Zip
Sex:
 Male
 Female
Ethnicity:
 Black
 Hispanic
 White/Other
I understand the information I am providing about age, sex, and ethnicity will not be used to determine eligibility for
employment but will be used solely for the purpose of obtaining criminal history record information.
Applicant for:
 Professional
 Certified Teacher
 Administrative Support/Paraprofessional
 Substitute Teacher
 Substitute Paraprofessional (Secretary/Aide)
 Student Teacher/Observer
Operations:
 Maintenance/Custodial
 Transportation
 Food Services
Substitute
 Maintenance/Custodial/Food Services
School District Volunteer:
 Campus/Classroom/Chaperone
 Other: ______________________
Please list campus or area: ___________________
(please list)
School District Volunteer/Student Teacher: My signature below indicates that I have been notified that a Computerized Criminal History
(CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on the
personal information I have entered above. Because the name based information is not an exact search and only fingerprint record searches
represent true identification of criminal history, the Navarro I.S.D., who conducting the criminal history check is not allowed to discuss any
information obtained with me using this method; therefore the Navarro I.S.D. may offer me the opportunity to have a fingerprint search
performed at my expense, to clear any misidentification based on name search, if the search provides a criminal report I know could not be
mine.
For employment purposes: I will be required to submit a full and complete set of my fingerprints for analysis through the Texas Department
of Public Safety AFIS. I have been made aware that in order to complete this process I must have the correct fingerprinting (FAST) form from
Navarro I.S.D., schedule the appointment, submit a full and complete set of my fingerprints and pay the fee of fingerprinting to L1 Enrollment
Services Company. Once I have completed this process and the Navarro I.S.D. receives the data from DPS, the information on my fingerprint
criminal history record may be discussed with me.
Signature: __________________________________________ Date:
==================================
CCH Report printed:

Yes
FOR DISTRICT USE ONLY
================================
 No Initial: _______ Purpose: __________________ Approved/Hired 
Date: ________________________________
Destroy Date: __________________
-3-
Yes
 No
__________
Initial: _________________
HR Forms 10/11